General Information

Mr.Mrs.

*First name :

*Last name :

*Phone :

Applicant

How many years have you had a driver's licence ?

Have you had your driver's licence suspended in the last 3 years ?YesNo

What is your occupation ?

*Do you belong to a group, association or professional order ?YesNo

If yes, which group, association or professional order do you belong to?

*Are you or have you ever been one of our clients ?YesNo

Type of RV

What type of RV are you looking to insure ?

Make :

Model :

Year :

Purchase date :

Number of claims in the last 3 years ?

Contact Preferences

When do you want us to call you ?MondayTuesdayWednesdayThursdayFriday

Between 8h30 a.m. and 12h00 p.m.Between 1 p.m. and 5 p.m.

Stay connected

Email:

I hereby authorize Lussier Dale Parizeau to send me information about its products and services by email (I will be able to modify my permission at any time):

Special offers, saving opportunities, contestsYesNo

Newsletter (general information and advice about the company and products)YesNo

Questions / Comments

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